The contribution of the German Development Cooperation to solving the Human Resources for Health Crisis in developing countries
Shortage of health staff– what is being done?
Von Kaspar Wyss & Helen Prytherch / Schweizerisches Tropen- und Public-Health Institut (Swiss TPH)
In November, 2006 the Swiss Centre for International Health was mandated to compile a report for the German Federal Ministry of Economic Cooperation and Development looking into the contributions the German Development Cooperation is making towards solving the crisis of human resources for health in developing countries. By taking up contact with people working for the various German agencies challenges and lessons learned were illustrated and openings for future efforts identified.
The crisis in human resources in the health sectors of developing countries and in particular in Sub-Saharan Africa has long been a point of concern for the German Development Cooperation. The consequences are felt at all levels of the system including in Health Ministries and amongst other partners of the German Government. Health workers with the “capacity” to deliver health interventions to their populations are the key to improving health outcomes. The implications of there not being enough health staff in the right places are quite simply that goals are not being achieved – from the health related Millennium Development Goals, to national heath sector goals, to the delivery of basic health care to populations in need.
At the district level the severity of the situation is laid bare. Demands for increased outputs are being made of the district health system by Global Health Initiatives, such as the “All by 2010” call for universal access to antiretroviral treatment worldwide, which bring with them implications for the staffing levels and skills mix needed. What we see instead is the cumulative effects of the weak linkages between planners and decision-makers over the years, a lack of accurate workforce data and a further erosion of an already depleted workforce by HIV and AIDS.
With decentralisation health management teams find themselves requiring new skills to lobby for needed staff at Local Government level. Persisting bureaucratic modalities get in the way of fast action - with valuable time being lost, for example, between a health student qualifying and their deployment to a working place. Limited career development opportunities for lower cadres, little attention paid to health and safety and burn out due to the distressing demands of work combine to leave health staff dispirited and exhausted.
All the German agencies unite in portraying the difficulties of tackling the human resources for health issue. It calls for a major involvement at macro level: this includes awareness of reform processes beyond the health sector such as decentralisation and civil service reform. Efforts towards good governance must also be taken into consideration – it being long recognised that corruption undermines any reform process. Furthermore, ministries of finance and other social sectors need to be on board too. It is precisely the complexity of the issue which has caused individual agencies to shy away from tackling it in the past. The German Development Cooperation stresses that to move forward not only is a multisectoral overview of a particular country required but also a strong linkage to the national level. Through such representation experiences from lower levels in the system – local government level, health facility level - can be fed back and debated with Ministries of health, other related Ministries and development partners alike.
With regards to human resource development, the German Development Cooperation has various instruments at its disposal. There are six main actors:
- Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) is a technical assistance agency active in international cooperation. The GTZ mainly works for the German Federal Ministry for Economic Co-operation and Development, but also operates on behalf of other German Ministries, partner country Governments and international clients, such as the European Commission, the United Nations and the World Bank.
- Kreditanstalt für Wiederaufbau (KfW) is involved in a wide number of financial activities. One work area of the German Development Bank is the provision of financial cooperation through loans and grants to support projects and programmes in developing countries on behalf of the German Federal Government.
- Deutscher Entwicklungsdienst (DED). The German Development Service places professional advisors in partner countries. They provide technical assistance and work at district, local government and even community level.
- Internationale Weiterbildung und Entwicklung (InWEnt). Capacity Building International, Germany offers a large variety of possibilities for exchange and professional development for staff from partner countries in their home countries, in other countries in the South or even in Germany.
- Centrum für Internationale Migration und Entwicklung (CIM) is a joint operation of the GTZ and the German Federal Employment Agency. It recruits experts from European markets to work in partner country institutions.
- Deutscher Akademischer Austausch Dienst (DAAD). The German Academic Exchange Service facilitates academic and research possibilities in Germany for scholars from around the world.
Contributions to the human resources situation
Deutsche Gesellschaft für Technische Zusammenarbeit: GTZ as the bilateral, technical agency enjoying a long term presence in partner countries is for the main part the agency responsible for ensuring the link to the national policy dialogue. In Indonesia, for example, the landscape of actors involved in Human Resources Development (HRD) is overall rather fragmented. GTZ is supporting the Ministry of Health in improvement of coordination between international and national stakeholders.
GTZ contributes to HRD in diverse ways ranging from support for strategic human resources planning as part of a health system's approach, to capacity building and technical assistance in many related areas such as which health cadres it makes most sense to invest in, to supporting closer collaboration between public and private health providers. The later may seem an unlikely area for an important contribution to HRD to be identified. However, in many countries where the German Development Cooperation supports the health sector up to 50% of service provision and a significant proportion of health staff training may be undertaken by non-state actors – religious associations, non-governmental organisations, foundations or private practitioners/colleges. By facilitating improved communication between private and public actors a contribution to the streamlining of wages and conditions is made. This can, in turn, result in a stronger, complementary effort towards wider health care provision.
Additionally, church run facilities have often made important experiences in the area of staff recognition and retention which the state could learn from. For example, GTZ supported the Church Health Association of Malawi to provide a modest incentive package for teaching staff who agreed to be located near to hospitals providing the possibility for clinical practice – the hospitals were all in extremely remote, rural areas. This began in the early 1990s and represents an early attempt to engage constructively with the human resources problematic which has shown enduring and positive results.
The above list of ways GTZ supports human resources directly and indirectly is far from exhaustive. A final approach that will be mentioned here is the GTZ BACKUP initiative. Set up in 2002, it works to assist partner countries to take advantage of the opportunities for funding provided by global initiatives in the field of HIV/AIDS, tuberculosis and malaria. It facilitates the development of relevant skills and know-how within local implementing institutions – including civil society organisations. In line with the WHO “3 by 5 initiative” to get 3 million people onto antiretroviral therapy by the end of 2005, GTZ and WHO both advocated for capacity building to take place via South-to South learning – that is through “knowledge hubs” in regions of the world that have already accumulated experiences and share the same cultural value system and resources levels. An example where this has been applied is the Centre International de Formation en Recherche Action (CIFRA) in Ouagadougou, Burkina Faso.
Kreditanstalt für Wiederaufbau: In the case of KfW the direct contribution to HR is more difficult to discern as financial cooperation is increasingly channelled through sector and budget support. Whilst it is not possible to earmark funding for use towards certain ends, the German Development Bank is in a position to lobby for the issue to be addressed in national priorities with measurable indicators that are followed, for example, in annual health sector reviews. The readiness of development partners to assist partner countries in covering the running costs of their health systems – including increases in staff wages – is also growing as the situation continues to deteriorate and it is clear than some states cannot introduce measures to remedy this unaided.
In addition, support for improvements to infrastructure plays an indirect role in the problematic; Rehabilitation of training institutions and hospitals help to enhance the working places of health staff and can increase overall motivation. Provision of staff housing in rural areas has been seen to have a link to recruitment. In the case of training institutions for annual intakes of health cadre students to increase there is often a need for more accommodation and classrooms.
Deutscher Entwicklungsdienst: DED’s key contribution lies in ensuring that the link to the district level is maintained. Experiences and challenges at this level are fed back to the national level through the German Development Co-operation’s programme structure. As an example, in Lindi, a much neglected and impoverished Region in the South of Tanzania, a church hospital and DED advisor arranged that good school leavers with an interest in health be supported to study at nearby Ndanda nursing school upon the premise that they then work at the hospital for a set time upon qualifying. By taking students from the locality the chances of retaining them are seen to be higher and the approach is being closely monitored.
Internationale Weiterbildung und Entwicklung: InWEnt’s contribution includes support for continuous professional development for health staff working on the ground – often lower cadres without academic titles and lacking the skills and support they need. Trainings are very practical in focus and always developed in close collaboration with employers.
Furthermore, capacity building at the institutional level – particularly of health training institutions in the South - is supported by InWEnt through a variety of strategies: study tours are arranged whereby officials from partner countries may visit Germany or another country in the South to gain exposure and learn by example. E-learning courses with a short, introductory face-to-face seminar and subsequent on-line sessions are becoming a useful tool as information technology infrastructure improves. This style of learning reduces the time that the person has to leave their workplace for. Courses using the “Training of Trainers“ Model are also facilitated, topics might be participatory or adult-centred learning. Additionally, health learning materials – books and medical models are made available. Provision of scholarships for students to study in local health institutions is also a key strategy which provides regular, predictable funding the institutions can plan with.
In Indonesia, although HRD is encapsulated in national reforms, since decentralisation got underway in 2001 the situation regarding the actual management of human resources has deteriorated. The devolving of power was very far-reaching, yet local governments face challenges in fulfilling their new functions. In the wake of these observations InWEnt began to offer a four weeks course on health district management with the Public Health School in Kapang via its regional office in Manila. The course content can be regarded as highly relevant covering health financing, epidemiology, leadership and human resources management. After the tsunami struck in 2004 human resources were tragically depleted even further. With reconstruction funding secured from the BMZ, InWEnt used it alumni networks to contact those staff who had survived, and via them the new staff put hastily in place, to offer the course in two of the most affected regions.
The capacity building approach of InWEnt is very much “hands-on” and focused upon the staff actually working at the “coalface” of health service provision rather than their previous qualifications. Whilst efforts are made to ensure training curricula gain national accreditation, the intention here is not to provide an academic title but to open up pathways of professional development for even the lowest cadres who often find themselves excluded from tertiary level studies.
Centrum für Internationale Migration und Entwicklung: CIM enables senior, qualified and experienced staff from Germany/the EU to work in Asia, Africa, Latin America and Eastern Europe. Nearly 600 European professionals are currently working and transferring skills and know-how through the CIM Integrated Experts Programme in 70 countries throughout the world.
CIM cooperates with senior public service and private employers in partner countries and undertakes recruitment in the EU on their behalf. A pre-selection is made with the final decision lying with the local employer. The recruited expert is subordinated to the local employer and structures, hence the term “integrated expert”. The contract of employment is provided by the local employer. Furthermore, CIM experts can make use of technical and/or financial support (provision of essential, missing working tools etc) via CIM headquarters in Frankfurt and has his/her local wage subsidised to European levels.
In addition, CIM actively recruits amongst specialists who have undertaken training in Germany and who are interested to return to their home countries. This is the so-called “Return and Reintegrate Programme”. Amongst academic diaspora who have come to work, study, teach and research in Germany for a variety of reasons CIM is a well known instrument. CIM provides those looking to repatriate with transport subsidies and topping up of wages for up to two years– benefits which greatly ease the financial implications of a relocation and reintegration into local public service. In addition, CIM negotiates with national authorities to clarify and seek recognition for qualifications such people have gained in Germany in other countries. In total between 600 and 700 qualified people return home with CIM support every year. Some of the key countries are Ethiopia, Ghana, Cameroon, India, Indonesia, Israel/Palestine and Syria. Overall between 50-60 health specialists leave Germany for the public sector in their home countries as part of this programme every year.
Whilst the numbers of people mentioned may seem small the approach is seen to be extremely useful. When the modest overall number of health specialists available in some partner countries is considered then it is clearly a case of every person counting and making a difference. Since 1994, CIM has supported 1,116 qualified Indonesians (approx.150 per year) to leave Germany via their “Return and Reintegration Programme”. This included 22 health specialists between 2005-2006.
In Malawi, as an extreme example, “gap filling” has been adopted as a strategy not only in the area of health teaching but also in curative areas. This means that expatriate Medical Doctors have and are being recruited to work at district level. The concept has been slow to get off the ground with problems arising around working cultures, language, differences of medical backgrounds and levels of remuneration. The Medical Council in Malawi has recognised that CIM is an instrument that has managed to recruit more specialised medical doctors and has requested the agency take a “facilitatory” role in introducing all the new expatriate staff, recruited by various international agencies, to the Malawian working environment.
Deutscher Akademischer Austausch Dienst: DAAD: facilitates academic and research possibilities in Germany for scholars from around the world. Medical training institutions with high numbers of foreign students are supported to implement packages of measures to help medical graduates return to their home country. During the course of their training this includes additional input in the areas of tropical medicine and appropriate technology as well as the facilitation of internships in the developing world. Continuous education options and alumni networks ensure contact with professionals outlasts the mere length of their time of study. A particularly successful example is the programme at the University of Heidelberg for medical students from Cameroon, Vietnam, Ethiopia and the Yemen where tracer studies show high rates of return and enduring contact to Germany.
Impact evaluations conducted with health professionals who have remained in DAAD alumni networks and frequently make use of opportunities to teach, research or attend short course in Germany show this approach to be highly motivating. This is particularly the case when the everyday working conditions are very difficult. This is a positive example of actively engaging with health worker diaspora within Europe. By promoting circulatory migration, health professionals who might otherwise simply migrate to Europe are encouraged and supported to be based and work the majority of the time in the home country to alleviate the shortage of skilled health staff, whilst remaining in touch with Europe and abreast of new developments in their field.
Findings and way forward
The various ways the instruments of the German Development Cooperation are at work in the different partner countries makes clear that there is no single, set solution to responding to the issue of human resources for health. The complexity of the issue calls for a diversified analysis at the country level and an enduring commitment. The German Development Cooperation comprises a relatively large number of agencies which means that a multifaceted response can be provided, albeit if at the same time close attention has to be paid to coordination and coherence. Common elements of a response which are identified by all the agencies include that strategies need to be in line with overall efforts to strengthen health systems, to be well linked to the policy level and coordinated with other reform processes. Whilst there is an ultimate need for political will and structural changes to take place, progress can be made through innovation at lower levels in the health system and the sharing of experiences as to what makes a difference. Some of the approaches outlined are undoubtedly of wider interest and can further stimulate the current debate on which strategies can help alleviate the crisis both now and in the longer term.
*This article summarises the content of a presentation made at the Spring Symposium “Human Resources for Health – Beyond the Declarations” on 23rd March, 2007. It is based upon a review commissioned by the German Federal Ministry of Economic Cooperation and Development (BMZ), financed by the German Technical Cooperation (GTZ) and conducted by the Swiss Centre for International Health. The views and ideas expressed herein are those of the authors and do not necessarily imply or reflect the opinion of the GTZ or BMZ. Further reading: “Contributions to Solving the Human Resources for Health Crisis in Developing Countries – with Special Reference to the German Development Cooperation”, (2006) Kaspar Wyss, Helen Prytherch, Ricarda Merkle, Svenja Weiss and Thomas Vogel.
Both authors work at the Swiss Centre for International Health a department of the Swiss Tropical Institute, “Improving Health Systems Worldwide”. Contact: Kaspar.Wyss@unibas.ch.